Abstract
Developed for scarless neck surgery and conceived as a modification of the axillo-bilateral breast approach, the bilateral axillo-breast approach (BABA) is a method of extracervical endoscopic thyroidectomy that is currently one of the most popular endoscopic thyroidectomy techniques in the world. Since the da Vinci robotic system was used to overcome many of the technical disadvantages of BABA endoscopic thyroidectomy, the indications of BABA robotic thyroidectomy(BABA-RT) could be largely extended, and currently include low-risk differentiated thyroid carcinoma <4 cm in diameter, benign thyroid nodule or follicular neoplasm <8 cm in diameter and Graves’ disease. Even modified radical neck dissection can be safely accomplished by BABA-RT. Candidates for BABA-RT should be carefully selected on the basis of thyroid pathology and patient factors. BABA-RT uses a midline approach to the thyroid, which provides a symmetrical view of the thyroid lobes that is similar to open thyroidectomy, so the operation process is familiar to surgeons. Evidence supports that BABA-RT is comparable to the open procedure in terms of completeness of surgical resection and rate of perioperative complications. BABA-RT is safe and feasible when performed by experienced surgeons on carefully selected patients concerned about neck scarring, but more expensive than open or endoscopic surgery.
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Keywords
- Bilateral axillo breast approach
- Robotic thyroidectomy
- Extra-cervical access
- Scarless thyroidectomy
- Endoscopic thyroidectomy indications
- Surgical technique
1 Background
The bilateral axillo-breast approach (BABA) is currently one of the most popular endoscopic thyroidectomy techniques in the world [1]. Since the first endoscopic parathyroidectomy was reported in 1996 [2], the development of minimally invasive thyroidectomy has been fueled by the need to eliminate neck scars [3, 4]. Currently, there are two main models of endoscopic approach to thyroidectomy [2]. The first involves techniques that reduce the scar length, making it less obviously visible, and include the popular minimally invasive video-assisted thyroidectomy described by Miccoli, as well as approaches made through an endoscopic lateral incision, lateral mini-incision, or postauricular incision [2]. The second model is extracervical endoscopic thyroidectomy, developed for scarless neck surgery. This includes the transaxillary approach [5], the axillo-breast approach, the anterior chest/breast approach, the bilateral breast approach, and the transoral endoscopic approach. Conceived as a modification of the axillo-bilateral breast approach by Shimazu et al. [6], the BABA was developed in 2007 by Choe et al. [7]. The initial experiences with BABA endoscopic thyroidectomy (BABA-ET) recorded satisfactory cosmetic outcomes but were associated with many technical challenges and safety concerns: with the use of straight rigid instruments without articulations and a two-dimensional camera view within the limitations of a narrow working space, the operation proved difficult to perform and the learning curve was longer than that of traditional surgical treatment [8]. Thus, BABA-ET could be applied to a small subset of patients only [3, 4]. With introduction of the da Vinci robotic system (Intuitive Surgical, Inc., Sunnyvale, CA, USA), hand tremor filtration, multi-articulated endo-wrist function, fine motion scaling, and three-dimensional magnification were used to overcome many technical disadvantages of BABA-ET, and the indications for BABA robotic thyroidectomy (BABA-RT) could be largely extended [9].
2 Indications and Patient Selection
A large body of evidence supports that BABA-RT can now be safely and effectively applied to the management of benign and malignant thyroid conditions [9,10,11].
BABA-RT currently has the following indications:
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low-risk differentiated thyroid carcinoma <4 cm in diameter
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minimal invasion of anterior thyroid capsule or strap muscle [11]
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benign thyroid nodule or follicular neoplasm <8 cm in diameter
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Graves’ disease (recommended for <100 mL in volume),
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suspicious lateral neck metastasis limited to levels IIa, III, IV, and Vb (modified radical neck dissection can be safely accomplished by BABA-RT [11])
Absolute contraindications to BABA-RT include huge substernal goiter, thyroid malignancies that are likely to recur (e.g., medullary, undifferentiated, or poorly differentiated thyroid carcinoma), distant metastasis, extrathyroidal invasion to larynx, trachea, esophagus, or recurrent laryngeal nerve (RLN) and prior irradiation to the neck or breast.
Relative contraindications are:
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Large-sized thyroid nodules >8 cm in diameter
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Thyroid malignancy laid posteriorly around the ligament of Berry and the RLN (unpredictable risk of RLN involvement)
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Patient with breast malignancy
BABA does not involve the breast parenchyma in the subcutaneous dissection, so previous breast surgery (modified radical mastectomy, breast-conserving surgery or breast augmentation) is not contraindicated. Previous thyroid or parathyroid surgery or cervical spine surgery is not contraindicated.
Candidates for BABA-RT should be carefully selected on the basis of thyroid pathology and patient factors [1, 12]. Although there is no age limit for BABA-RT, most surgeons operate on patients <70Â years of age [13]. BABA-RT can be safely conducted on both sexes, though male sex has been an independent factor predicting difficult surgery [14]. Obesity is generally considered a relative contraindication [15].
3 Procedure
BABA-RT uses a midline approach to the thyroid, which provides a 3D symmetrical view of both thyroid lobes with optimal visualization and dissection of vital structures, and enables large operative angles between the instruments that can prevent instrument crowding or fighting. The thyroid dissection method in BABA is similar to that of open thyroidectomy, so the operation process is familiar to surgeons. The learning curve of BABA-RT is about 40 cases [16].
The robotic platforms used are da Vinci S, Si or Xi (Intuitive, USA), with the following EndoWrist instruments: graspers (Maryland bipolar and ProGrasp forceps) and electrocautery hook. The patient is positioned supine on the operating table, with the armpits opened slightly to aid axillary incisions, and the neck extended by placing a pillow under the patient’s shoulders. The operative field is prepped and draped as a large area including the neck and the patient’s chest. The robot location is at the patient’s shoulder for the da Vinci S, Si, while the da Vinci Xi system can be placed on either side. The ventilator is usually positioned at the patient’s feet or right side of the patient. Guidelines are drawn with a marker along the landmarks of the anterior chest and the neck: midline, thyroid cartilage, cricoid cartilage, anterior border of the sternocleidomastoid muscle, the clavicles, suprasternal notch, four incisions, trajectory lines from the port site to the neck, and the working spaces (Fig. 10.1) [4].
Epinephrine-mixed saline solution (1:200,000) is injected in the working space under the platysma muscles in the neck and anterior chest, forming a saline pocket in the subplatysmal layer, which can reduce bleeding in the flap and make the dissection easier.
Two 8-mm incisions are made in both axillae and blunt dissection is performed to elevate the flap using straight mosquito hemostats and a vascular tunneler. The ports are then inserted through the incisions. Two ports should be inserted to meet in the middle. The working space is insufflated with CO2 at 6Â mmHg through the left axillary port. This pressure solved the earlier problems of hypercarbia, tachycardia, respiratory acidosis, subcutaneous emphysema, and air embolism with >10Â mmHg of CO2 [17].
Sharp dissection is started in Area 1 of the anterior chest with the harmonic shear and, once completed, two incisions are made at the superomedial margin of the areolae; the flap is now extended to Area 2, up to the cricoid cartilage (Fig.10.1).
In the da Vinci S and Si systems, the robot column is aligned with the camera port of the right breast, while the da Vinci Xi system is placed in the middle. The robotic arms are docked to each 8-mm port and the camera is inserted through the 12-mm right breast port. A monopolar electrocautery or ultrasonic shear is inserted through the left breast port. Graspers are inserted through both axillary ports and further flap dissection is performed.
The midline between the strap muscles is divided from the suprasternal notch to the thyroid cartilage to expose the thyroid gland and the trachea. To help visualize the midline, the assistant may palpate the thyroid cartilage while inside it is marked with electrocautery. After dividing the midline, the isthmus is divided with the harmonic shear. Isthmectomy helps to retract the thyroid gland more easily.
The thyroid gland is retracted medially with ProGrasp forceps, and the right side of the strap muscles is retracted laterally using Maryland forceps. The strap muscles are thoroughly dissected off the thyroid capsule and lateral dissection is performed down to the common carotid artery. The thyroid lobe can be effectively retracted by manipulating the third and fourth robot arms, gradually pulling and switching their mutual positions.
While dissecting the lower pole, large vessels such as the inferior thyroid vein and the thyroid ima artery are ligated with bipolar electrocautery or ultrasonic shears, but only after the RLN has been identified. When lateral dissection is complete, the inferior thyroid artery and inferior parathyroid gland (PT) can be seen.
The RLN is found between the common carotid artery and trachea (tracheoesophageal groove). Once identified, the RLN can be confirmed using a nerve monitor. The inferior PT, which should be carefully preserved, sits around the lower pole of the gland, over the RLN.
Dissection is continued to the upper part near the point of RLN entry into the larynx under the cricopharyngeal muscle. The nerve may divide into a couple of branches along its course from the level of the inferior thyroid artery to the larynx. The ligament of Berry is the most frequent site of nerve injuries. A cotton ball is used to protect the nerve from thermal and mechanical damage.
Drawing the upper third of the strap muscles laterally with the Maryland forceps, the ultrasonic shears is used to dissect the vessels of the upper pole. Here, an anteromedial approach is recommended to avoid injury to the superior laryngeal nerve. Care must be taken to preserve the superior PT, as it is usually located under the RLN.
After thyroid lobectomy is completed, the specimen wrapped in the endobag is pulled out through the left axillary port. If the left axillary incision is not wide enough to extract the specimen, it can be extended posteriorly along the axillary crease.
After meticulous hemostasis, the strap muscles are approximated with a continuous running suture. Optionally, a Jackson-Pratt drain can be placed into the operative fields through the right or left axillary incision.
The skin incisions are closed with a subcuticular absorbable suture and the incision is dressed. The anterior chest is compressed with a Robo-Bra to reduce emphysema, postoperative bleeding and pain.
4 Outcomes and Cost
The main purpose of robotic thyroidectomy is to achieve better patient satisfaction with cosmetic outcomes. BABA-RT consistently recorded better cosmetic satisfaction than open thyroidectomy (OT) [15, 17,18,19].
In the literature, the operating time of BABA-RT was 1.3–2.4 times longer than that of OT [16, 18, 20,21,22], which may increase medical expenses. In remote access robotic thyroidectomy flap dissection can be a time-limiting procedure. However, the time required for flap dissection and robot docking gradually decreases with the experience of the surgical team [16, 20].
Studies investigating postoperative pain suggest that BABA-RT caused similar or less pain to patients than OT [19, 21, 23]. Prospective observational studies reported that about 40% of patients experienced transient paresthesia of the anterior chest after BABA-RT, which normalized within 3Â months [24].
Drain output [25, 26] and hospital stay (mean, 3 to 5Â days) [11, 18, 20, 21, 23, 25, 27] were found to be similar between BABA-RT and OT.
No significant difference was observed between BABA-RT and OT in the rates of transient and permanent RLN injuries [11, 18,19,20,21,22,23, 25, 27, 28].
In most studies examining BABA-RT, hypoparathyroidism was defined by hypocalcemic symptoms and low parathyroid hormone level (<15Â pg/dL), and it was permanent when symptoms continued for more than 6Â months [19, 23, 29]. The rates of permanent hypoparathyroidism were comparable between BABA-RT and OT [11, 18, 19, 21,22,23, 25, 27,28,29,30].
The reported rates of postoperative bleeding and hematoma after BABA-RT was 0–0.9%, not significantly different from OT [11, 18,19,20,21,22,23, 25, 27, 29].
Current evidence supports that BABA-RT is comparable to OT in terms of completeness of surgical resection [28]. Central neck dissection can be performed down to the common carotid artery and distal innominate artery, although there are mixed results in the literature in terms of the lymph node yield of BABA-RT compared to OT [19]. No significant difference was observed in the absolute level of stimulated thyroglobulin between BABA-RT and OT [20, 22, 23, 25, 27,28,29]. No difference in the uptake on whole-body scan after radioactive iodine (RAI) therapy, number of RAI sessions, and the RAI dose between BABA-RT and OT [28].
The evidence on locoregional recurrence and disease-specific survival after BABA-RT is limited. In a study that compared BABA-RT and OT for 2–4 cm papillary thyroid carcinoma, no recurrence was observed in both groups in a median follow-up of 40.2 months [22].
BABA-RT is comparable to OT in terms of complications and is safe and feasible when performed by experienced surgeons and on carefully selected patients concerned about neck scarring.
Robotic surgery is more expensive than open or endoscopic surgery, with the cost of BABA-RT recorded at 2.5–6.2 times higher than OT [18, 23, 25]. With robotic systems and procedures evolving, it is likely that more cost-effective ways will be found to provide safe and complete surgery that offers improved quality of life.
References
Berber E, Bernet V, Fahey TJ 3rd, et al. American Thyroid Association statement on remote-access thyroid surgery. Thyroid. 2016;26(3):331–7.
Wong KP, Lang BHH. Endoscopic thyroidectomy: a literature review and update. Curr Surg Rep. 2013;1(1):7–15.
Chung YS, Choe JH, Kang KH, et al. Endoscopic thyroidectomy for thyroid malignancies: comparison with conventional open thyroidectomy. World J Surg. 2007;31(12):2302–6.
Choi JY, Lee KE, Chung KW, et al. Endoscopic thyroidectomy via bilateral axillo-breast approach (BABA): review of 512 cases in a single institute. Surg Endosc. 2012;26(4):948–55.
Prete FP, Marzaioli R, Lattarulo S, et al. Transaxillary robotic-assisted thyroid surgery: technique and results of a preliminary experience on the Da Vinci xi platform. BMC Surg. 2019;18(Suppl 1):19.
Shimazu K, Shiba E, Tamaki Y, et al. Endoscopic thyroid surgery through the axillo-bilateral-breast approach. Surg Laparosc Endosc Percutan Tech. 2003;13(3):196–201.
Choe JH, Kim SW, Chung KW, et al. Endoscopic thyroidectomy using a new bilateral axillo-breast approach. World J Surg. 2007;31(3):601–6.
Liang TJ, Tsai CY, Liu SI, Chen IS. Multidimensional analyses of the learning curve of endoscopic thyroidectomy. World J Surg. 2021;45(5):1446–56.
Lee KE, do Koo H, Kim SJ, et al. Outcomes of 109 patients with papillary thyroid carcinoma who underwent robotic total thyroidectomy with central node dissection via the bilateral axillo-breast approach. Surgery. 2010;148(6):1207–13.
Lee HY, Yang IS, Hwang SB, et al. Robotic thyroid surgery for papillary thyroid carcinoma: lessons learned from 100 consecutive surgeries. Surg Laparosc Endosc Percutan Tech. 2015;25(1):27–32.
Kwon H, Yi JW, Song RY, et al. Comparison of bilateral axillo-breast approach robotic thyroidectomy with open thyroidectomy for graves’ disease. World J Surg. 2016;40(3):498–504.
Liu SY, Ng EK. Robotic versus open thyroidectomy for differentiated thyroid cancer: an evidence-based review. Int J Endocrinol. 2016;2016:4309087.
Lee KE, Kim E, do Koo H, et al. Robotic thyroidectomy by bilateral axillo-breast approach: review of 1026 cases and surgical completeness. Surg Endosc. 2013;27(8):2955–62.
Kwak HY, Kim HY, Lee HY, et al. Predictive factors for difficult robotic thyroidectomy using the bilateral axillo-breast approach. Head Neck. 2016;38(Suppl 1):E954–60.
Lee HS, Chai YJ, Kim SJ, et al. Influence of body habitus on the surgical outcomes of bilateral axillo-breast approach robotic thyroidectomy in papillary thyroid carcinoma patients. Ann Surg Treat Res. 2016;91(1):1–7.
Kim WW, Jung JH, Park HY. The learning curve for robotic thyroidectomy using a bilateral axillo-breast approach from the 100 cases. Surg Laparosc Endosc Percutan Tech. 2015;25(5):412–6.
Yu HW, Yi JW, Seong CY, et al. Development of a surgical training model for bilateral axillo-breast approach robotic thyroidectomy. Surg Endosc. 2018;32(3):1360–7.
Kwak HY, Kim HY, Lee HY, et al. Robotic thyroidectomy using bilateral axillo-breast approach: comparison of surgical results with open conventional thyroidectomy. J Surg Oncol. 2015;111(2):141–5.
He Q, Zhu J, Fan Z, et al. Robotic thyroidectomy with central neck dissection using axillo-bilateral-breast approach: a comparison to open conventional approach. Zhonghua Wai Ke Za Zhi. 2016;54(1):51–5.
Kim WW, Jung JH, Park HY. A single surgeon's experience and surgical outcomes of 300 robotic thyroid surgeries using a bilateral axillo-breast approach. J Surg Oncol. 2015;111(2):135–40.
Chai YJ, Song J, Kang J, et al. A comparative study of postoperative pain for open thyroidectomy versus bilateral axillo-breast approach robotic thyroidectomy using a self-reporting application for iPad. Ann Surg Treat Res. 2016;90(5):239–45.
Chai YJ, Suh H, Woo JW, et al. Surgical safety and oncological completeness of robotic thyroidectomy for thyroid carcinoma larger than 2 cm. Surg Endosc. 2017;31(3):1235–40.
Cho JN, Park WS, Min SY, et al. Surgical outcomes of robotic thyroidectomy vs. conventional open thyroidectomy for papillary thyroid carcinoma. World J Surg Oncol. 2016;14(1):181.
Kim SJ, Lee KE, Myong JP, et al. Prospective study of sensation in anterior chest areas before and after a bilateral axillo-breast approach for endoscopic/robotic thyroid surgery. World J Surg. 2013;37(5):1147–53.
Seup Kim B, Kang KH, Park SJ. Robotic modified radical neck dissection by bilateral axillary breast approach for papillary thyroid carcinoma with lateral neck metastasis. Head Neck. 2015;37(1):37–45.
He QQ, Zhu J, Zhuang DY, et al. Comparative study between robotic total thyroidectomy with central lymph node dissection via bilateral axillo-breast approach and conventional open procedure for papillary thyroid microcarcinoma. Chin Med J. 2016;129(18):2160–6.
Kim WW, Kim JS, Hur SM, et al. Is robotic surgery superior to endoscopic and open surgeries in thyroid cancer? World J Surg. 2011;35(4):779–84.
Lee KE, do Koo H, Im HJ, et al. Surgical completeness of bilateral axillo-breast approach robotic thyroidectomy: comparison with conventional open thyroidectomy after propensity score matching. Surgery. 2011;150(6):1266–74.
Kim BS, Kang KH, Kang H, Park SJ. Central neck dissection using a bilateral axillo-breast approach for robotic thyroidectomy: comparison with conventional open procedure after propensity score matching. Surg Laparosc Endosc Percutan Tech. 2014;24(1):67–72.
Yu HW, Chai YJ, Kim SJ, et al. Robotic-assisted modified radical neck dissection using a bilateral axillo-breast approach (robotic BABA MRND) for papillary thyroid carcinoma with lateral lymph node metastasis. Surg Endosc. 2018;32(5):2322–7.
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Prete, F. et al. (2024). Robotic Bilateral Axillo-Breast Approach. In: Testini, M., Gurrado, A. (eds) Thyroid Surgery. Updates in Surgery. Springer, Cham. https://doi.org/10.1007/978-3-031-31146-8_10
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